@extends('layouts.default')  
@section('content')
    <div class="box primary">
        <header>
            <div class="icons">
                <i class="fa fa-edit"></i>
            </div>
            <h5>{{Lang::get('customer.customer_data')}}</h5>
            <!-- .toolbar -->
            <div class="toolbar">
                <nav style="padding: 8px;">
                    <a href="javascript:;" class="btn btn-default btn-xs collapse-box">
                        <i class="fa fa-minus"></i>
                    </a> 
                    <a href="javascript:;" class="btn btn-default btn-xs full-box">
                        <i class="fa fa-expand"></i>
                    </a> 
                    <a href="javascript:;" class="btn btn-danger btn-xs close-box">
                        <i class="fa fa-times"></i>
                    </a> 
                </nav>
            </div>
        </header>
        <div id="div-1" class="body">
            {{ Form::open(array('url' => 'customer_store', 'class'=>'form-horizontal','id'=>'form-validate')) }} 
            <div class="form-group">
                {{ Form::label('drfirstname', Lang::get('customer.drfirstname').'*', array('class'=>'control-label col-lg-4')) }}
                <div class="col-lg-8">
                    {{ Form::text('drfirstname','', array(
                                'placeholder' =>Lang::get('customer.drfirstname'),
                                'class' => 'form-control')) 
                    }}
                </div>
            </div>            
            <div class="form-group">
                {{ Form::label('drlastname', Lang::get('customer.drlastname').'*', array('class'=>'control-label col-lg-4')) }}
                <div class="col-lg-8">
                    {{ Form::text('drlastname',Input::old('drlastname'), array(
                                'placeholder' =>Lang::get('customer.drlastname'),
                                'class' => 'form-control')) 
                    }}
                </div>
            </div>      
            <div class="form-group">
                {{ Form::label('drbdate', Lang::get('customer.drbdate'), array('class'=>'control-label col-lg-4')) }}
                <div class="col-lg-8">
                    {{ Helpers\Helper::date('drbdate', isset($v->drbdate) ? $v->drbdate : '' , array(
                                'class' => 'form-control')) 
                    }}
                </div>
            </div>  
            <div class="form-group">
                {{ Form::label('draddress', Lang::get('customer.draddress'), array('class'=>'control-label col-lg-4')) }}
                <div class="col-lg-8">
                    {{ Form::text('draddress',Input::old('draddress'), array(
                                'placeholder' =>Lang::get('customer.draddress'),
                                'class' => 'form-control')) 
                    }}
                </div>
            </div> 
            <div class="form-group">
                {{ Form::label('drhphone', Lang::get('customer.drhphone'), array('class'=>'control-label col-lg-4')) }}
                <div class="col-lg-8">
                    {{ Form::text('drhphone',Input::old('drhphone'), array(
                                'placeholder' =>Lang::get('customer.drhphone'),
                                'class' => 'form-control')) 
                    }}
                </div>
            </div> 
            <div class="form-group">
                {{ Form::label('drcountry', Lang::get('customer.drcountry'), array('class'=>'control-label col-lg-4')) }}
                <div class="col-lg-8">
                    {{ Form::text('drcountry',Input::old('drcountry'), array(
                                'placeholder' =>Lang::get('customer.drcountry'),
                                'class' => 'form-control')) 
                    }}
                </div>
            </div>
            <div class="form-group">
                {{ Form::label('drlicnr', Lang::get('customer.drlicnr'), array('class'=>'control-label col-lg-4')) }}
                <div class="col-lg-8">
                    {{ Form::text('drlicnr',Input::old('drlicnr'), array(
                                'placeholder' =>Lang::get('customer.drlicnr'),
                                'class' => 'form-control')) 
                    }}
                </div>
            </div>
            <div class="form-group">
                {{ Form::label('cardnr', Lang::get('customer.cardnr').'*', array('class'=>'control-label col-lg-4')) }}
                <div class="col-lg-8">
                    {{ Form::text('cardnr',Input::old('cardnr'), array(
                                'placeholder' =>Lang::get('customer.cardnr'),
                                'class' => 'form-control')) 
                    }}
                </div>
            </div>
            <div class="form-group">
                {{ Form::label('drplace', Lang::get('customer.drplace'), array('class'=>'control-label col-lg-4')) }}
                <div class="col-lg-8">
                    {{ Form::text('drplace',Input::old('drplace'), array(
                                'placeholder' =>Lang::get('customer.drplace'),
                                'class' => 'form-control')) 
                    }}
                </div>
            </div>
            <div class="form-group">
                {{ Form::label('drliccat', Lang::get('customer.drliccat').'*', array('class'=>'control-label col-lg-4')) }}
                <div class="col-lg-8">
                    {{ Form::text('drliccat',Input::old('drliccat'), array(
                                'placeholder' =>Lang::get('customer.drliccat'),
                                'class' => 'form-control')) 
                    }}
                </div>
            </div>
            <div class="form-group">
                {{ Form::label('drpasportid', Lang::get('customer.drpasportid').'*', array('class'=>'control-label col-lg-4')) }}
                <div class="col-lg-8">
                    {{ Form::text('drpasportid',Input::old('drpasportid'), array(
                                'placeholder' =>Lang::get('customer.drpasportid'),
                                'class' => 'form-control')) 
                    }}
                </div>
            </div>
            <div class="form-group">
                {{ Form::label('DREMAIL', Lang::get('customer.DREMAIL').'*', array('class'=>'control-label col-lg-4')) }}
                <div class="col-lg-8">
                    {{ Form::text('DREMAIL',Input::old('DREMAIL'), array(
                                'placeholder' =>Lang::get('customer.DREMAIL'),
                                'class' => 'form-control')) 
                    }}
                </div>
            </div>
            <div class="form-group">
                {{ Form::label('drcity', Lang::get('customer.drcity'), array('class'=>'control-label col-lg-4')) }}
                <div class="col-lg-8">
                    {{ Form::text('drcity',Input::old('drcity'), array(
                                'placeholder' =>Lang::get('customer.drcity'),
                                'class' => 'form-control')) 
                    }}
                </div>
            </div>
            <div class="form-group">
                {{ Form::label('nrPikeve', Lang::get('customer.nrPikeve'), array('class'=>'control-label col-lg-4')) }}
                <div class="col-lg-8">
                    {{ Form::text('nrPikeve',Input::old('nrPikeve'), array(
                                'placeholder' =>Lang::get('customer.nrPikeve'),
                                'class' => 'form-control')) 
                    }}
                    <br/>
                    <div id="validation-div" class="">
                    </div>
                </div>
            </div>
            {{ Form::submit(Lang::get('messages.save_btn'), array('class' => 'btn btn-success btn-line')) }}
            <input type="button" value="{{ Lang::get('messages.cancel_btn')}}" class="btn btn-danger btn-line" onClick="history.go(-1);
                    return true;">
            {{ Form::close() }}
        </div>
    </div> 
@stop
